1699236497 NPI number — WEBSTER FAMILY PRACTICE

Table of content: (NPI 1699236497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699236497 NPI number — WEBSTER FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEBSTER FAMILY PRACTICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699236497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATHISTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39752-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-634-3089
Provider Business Mailing Address Fax Number:
662-634-3063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24849 MS HIGHWAY 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATHISTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39752-6900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-634-3089
Provider Business Practice Location Address Fax Number:
662-634-3063
Provider Enumeration Date:
03/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GARNETT
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
662-634-3089

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1122955 . This is a "FICTITIOUS NAME" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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